What is the role of radiographs in the diagnosis, prognosis and treatment of periodontal diseaseRadiographs are a valuable aid in the diagnosis of periodontal disease, determination of the prognosis, and evaluation of the outcome of treatment. However, the radiograph is an adjunct to the clinical examination, not a substitute for it.
Radiographs are used as an adjunct to the clinical examination completed my the clinician. It is important to take good radiographs in order to get an accurate representation of the bone and lamina dura. Radiographs should be out at all times during treatment and the clinician should be correlating the clinical findings to the radiographs.
It is important that the clinician take excellent radiogrpahs. In addition to what is stated above as the value and importance of radiographs, radiographs also reveals alterations in calcified tissue, radioopaque, and radiolucent lesions. Even though radiographs do not show any current cellular activity, radiographs do presents the the effects of cellular activity on the bone and roots. Excellent radiographs have more than just the landmarks and open contacts. Rather excellent radiographs have all landmarks, open contacts therefore meaning proper horizontal angulation, as well as proper vertical angulation. The clinician will assess the radiographs in order to ensure that they are excellent. In order to check vertical angulation the clinician will evaluate if the occlusal surface is seen on the radiogrpah therefore showing a buccal and lingual cusp instead of the two imposed on one and other.
Normal interdental septa:
Radiographic evaluation of the bone changes in periodontal disease is based mainly on the appearance of the appearance of the interdental septa, because of the relatively dense root structure obscures facial and lingual bony plates.
Prichard established the following four criteria to determine adequate angulation of periapical radiographs:
The radiograph should show the tips of the molar cusps with little or none of the occlusal surface showing.
Enamel caps and pulp chambers should be distinct.
Interproximal spaces should be open.
Proximal contacts should not be overlap unless teeth are out of line anatomically.
Pattern of Bone Destruction:
With periodontal disease structures like the lamina dura and interdental septa undergo changes in their height or contour. The radiograph will show the inderdental septa having vertical or horizontal bone loss.When a change has been seen in the height or contour it means that the disease has gone past the early stage of periodontitis.
The bitewing radiograph serves to asses the height of the alveolar crest and the bone remaining rather than the amount of lost. More specifically, vertical bitewings are recommended for patients with moderate to severe periodontal disease. The vertical bitewings with proper vertical angulation will determine and confirm the severity of the bone loss and identify the height reduction of the alveolar crest. It allows the clinician to establish the distribution of the bone loss. This diagnostic tool along with the clinical findings allows the clinician establish the patient's ADA, AAP, and prognosis. MC#3
The radiograph image tends to show less severe bone loss than what's is present clinically. The earliest signs of periodontal disease can be detected clinically (Carranza page 562). GE#6
There are four radiographic changes seen in periodontitis:
a. Pattern of bone loss: Horizontal and vertical bone loss
b. Fuzziness and break in the continuity of the lamina dura and alveolar crest. This could be a result from the extension of gingival inflammation into the bone. It is well noted that when the lamina dura is present and intact, this is a clear indication of periodontal health. If radiolucencies can be seen in the furcation areas radiographically, then there is furcation involvement.
c, Wedge-shape radiolucent areas on the mesials and/or the distals of the alveolar crest. This represents bone resoprtion in the lateral areas of the alveolar crest which could be associated with the widening of the PDL.
d. Height of the alveolar crest is reduced. This demonstrates bone destruction which extends across the alveolar crest. The trabecular pattern is inconsistent. The height of the alveolar crest has continuous reduction which is due to the inflammation of the gingiva an followed by bone resorption.
With new technology such as digital radiograph we can measure the amount of bone loss when we have a baseline to compare it to. The technique is called "Subtraction Radiography" where with technique sensitive procedure we can measure the amount of bone loss that has occurred since digital radiography is more sensitive than traditional. SR#14
Radiographic Appearance of Periodontal Disease
Periodontitis sequence of destruction:
The first apperances of periodontitis is fuzziness and a break in the connection of the lamina dura at the mesial or distal aspect of the interdental septum. This is do to an extension of gingival inflammation into the underlying bone causing a reduction of the calcified tissue. As the disease continues a wedge shaped radiolucent area is formed at the mesial or distal aspect of the crest of the septal bone. This is a result of resorption of the bone on the lateral aspect of the interdental septum. The destructive process continues across the crest of the interdental septum, causing a reduction in height. Fingerlike radiolucent projections extend from the crest into the septum. This is a result of further extension of inflammation into the bone. Continued destruction results in severe bone loss. (Carranza 565)
Furcation involvement:
With furcation involvement if a radiolucency is noted on a tooth different angles need to be seen to clearly understand the level of bone loss that has occurred. Radiographs are used to supplement the diagnosis of a furcation. The definitive way to diagnose a furcation is to use a nabers probe. It is important to check for furcation involvment when the radiographic density of the furcation is less dense than the trabecular pattern seen throughout healthy bone. If there is any radiolucency on the distal or mesial of a multirooted tooth the clinician should use check for furcation involvement.
Periodontal Abscess:
Radiographically a periodontal abscess is seen as a radiolucency on the lateral border of the roots in the late stages. In the early stages the patient may feel discomfort but nothing radiographically is seen. The location of the radiolucency does not reflect the amount of damage that has occurred in a periodontal abcess. The location is also not defined in a radiograph since it is 2 dimesional.
Clinical probing:
Radiographs taken with periodontal probes or other indicators placed into the anesthestized pocket show the true extent of the bone lesion. The use of radiopaque indicators is an efficient diagnostic aid for the clinician to visualize the bony defect. (Carranza 569). They can locate the area where the pocket is located but no depth.
Localized Aggressive Periodontitis:
LAP is characterized by a combination of the following radiographic features: (1) bone loss may occur initially in the maxillary and mandibular incisor and or first molar areas, this usually occurs bilateraly, and causes vertical bony defects; (2) Loss of alveolar bone may become generalized as the disease progresses but remains less pronounced in the premolar area (Carranza 571)
Trauma from Occlusion:
Trauma from occlusion can produce radiographically detectable changes in the lamina dura, morphology of the alveolar crest, width of the periodontal ligament sapce, and density of the surrounding cancellous bone. (Carranza 571)
Diseases Manifested in the Jaws
There are skeletal disturbances that may present themselves in the mandible and maxillary bone, and therefore may be revealed in radiographs.
Certain characteristics are noted for the particular disturbance. Osteitis fibrosa cystica, also known as Recklinghausen's disease, may result in "a diffuse granular mottling, scattered cystlike radiolucent areas throughout the jaws, and a generalized disappearance of the lamina dura" (Carranza, 574). Paget's disease would cause the trabecular bone pattern to be wool-like in appearance with an absent lamina dura. A patient with fibrous dysplasia would present a trabecular pattern with a ground-glass appearance or simply a small radiolucent area at a root apex. Other disturbances that will be noted during a radiographic interpretation include Langerhans cell histiocytosis, multiple myeloma, oteopetrosis, scleroderma and even a malignancy. Any disturbance affecting the bone will have an impact on the patient's prognosis and treatment, and therefore radiographs must be properly taken and interpreted (TL 8).
Radiographs are used as an adjunct to the clinical examination completed my the clinician. It is important to take good radiographs in order to get an accurate representation of the bone and lamina dura. Radiographs should be out at all times during treatment and the clinician should be correlating the clinical findings to the radiographs.
It is important that the clinician take excellent radiogrpahs. In addition to what is stated above as the value and importance of radiographs, radiographs also reveals alterations in calcified tissue, radioopaque, and radiolucent lesions. Even though radiographs do not show any current cellular activity, radiographs do presents the the effects of cellular activity on the bone and roots. Excellent radiographs have more than just the landmarks and open contacts. Rather excellent radiographs have all landmarks, open contacts therefore meaning proper horizontal angulation, as well as proper vertical angulation. The clinician will assess the radiographs in order to ensure that they are excellent. In order to check vertical angulation the clinician will evaluate if the occlusal surface is seen on the radiogrpah therefore showing a buccal and lingual cusp instead of the two imposed on one and other.
Normal interdental septa:
Radiographic evaluation of the bone changes in periodontal disease is based mainly on the appearance of the appearance of the interdental septa, because of the relatively dense root structure obscures facial and lingual bony plates.
Prichard established the following four criteria to determine adequate angulation of periapical radiographs:
- The radiograph should show the tips of the molar cusps with little or none of the occlusal surface showing.
- Enamel caps and pulp chambers should be distinct.
- Interproximal spaces should be open.
- Proximal contacts should not be overlap unless teeth are out of line anatomically.
Pattern of Bone Destruction:With periodontal disease structures like the lamina dura and interdental septa undergo changes in their height or contour. The radiograph will show the inderdental septa having vertical or horizontal bone loss.When a change has been seen in the height or contour it means that the disease has gone past the early stage of periodontitis.
The bitewing radiograph serves to asses the height of the alveolar crest and the bone remaining rather than the amount of lost. More specifically, vertical bitewings are recommended for patients with moderate to severe periodontal disease. The vertical bitewings with proper vertical angulation will determine and confirm the severity of the bone loss and identify the height reduction of the alveolar crest. It allows the clinician to establish the distribution of the bone loss. This diagnostic tool along with the clinical findings allows the clinician establish the patient's ADA, AAP, and prognosis. MC#3
The radiograph image tends to show less severe bone loss than what's is present clinically. The earliest signs of periodontal disease can be detected clinically (Carranza page 562). GE#6
There are four radiographic changes seen in periodontitis:
a. Pattern of bone loss: Horizontal and vertical bone loss
b. Fuzziness and break in the continuity of the lamina dura and alveolar crest. This could be a result from the extension of gingival inflammation into the bone. It is well noted that when the lamina dura is present and intact, this is a clear indication of periodontal health. If radiolucencies can be seen in the furcation areas radiographically, then there is furcation involvement.
c, Wedge-shape radiolucent areas on the mesials and/or the distals of the alveolar crest. This represents bone resoprtion in the lateral areas of the alveolar crest which could be associated with the widening of the PDL.
d. Height of the alveolar crest is reduced. This demonstrates bone destruction which extends across the alveolar crest. The trabecular pattern is inconsistent. The height of the alveolar crest has continuous reduction which is due to the inflammation of the gingiva an followed by bone resorption.
With new technology such as digital radiograph we can measure the amount of bone loss when we have a baseline to compare it to. The technique is called "Subtraction Radiography" where with technique sensitive procedure we can measure the amount of bone loss that has occurred since digital radiography is more sensitive than traditional. SR#14
Radiographic Appearance of Periodontal Disease
Periodontitis sequence of destruction:
- The first apperances of periodontitis is fuzziness and a break in the connection of the lamina dura at the mesial or distal aspect of the interdental septum. This is do to an extension of gingival inflammation into the underlying bone causing a reduction of the calcified tissue. As the disease continues a wedge shaped radiolucent area is formed at the mesial or distal aspect of the crest of the septal bone. This is a result of resorption of the bone on the lateral aspect of the interdental septum. The destructive process continues across the crest of the interdental septum, causing a reduction in height. Fingerlike radiolucent projections extend from the crest into the septum. This is a result of further extension of inflammation into the bone. Continued destruction results in severe bone loss. (Carranza 565)
Furcation involvement:- With furcation involvement if a radiolucency is noted on a tooth different angles need to be seen to clearly understand the level of bone loss that has occurred. Radiographs are used to supplement the diagnosis of a furcation. The definitive way to diagnose a furcation is to use a nabers probe. It is important to check for furcation involvment when the radiographic density of the furcation is less dense than the trabecular pattern seen throughout healthy bone. If there is any radiolucency on the distal or mesial of a multirooted tooth the clinician should use check for furcation involvement.
Periodontal Abscess:- Radiographically a periodontal abscess is seen as a radiolucency on the lateral border of the roots in the late stages. In the early stages the patient may feel discomfort but nothing radiographically is seen. The location of the radiolucency does not reflect the amount of damage that has occurred in a periodontal abcess. The location is also not defined in a radiograph since it is 2 dimesional.
Clinical probing:- Radiographs taken with periodontal probes or other indicators placed into the anesthestized pocket show the true extent of the bone lesion. The use of radiopaque indicators is an efficient diagnostic aid for the clinician to visualize the bony defect. (Carranza 569). They can locate the area where the pocket is located but no depth.
Localized Aggressive Periodontitis:- LAP is characterized by a combination of the following radiographic features: (1) bone loss may occur initially in the maxillary and mandibular incisor and or first molar areas, this usually occurs bilateraly, and causes vertical bony defects; (2) Loss of alveolar bone may become generalized as the disease progresses but remains less pronounced in the premolar area (Carranza 571)
Trauma from Occlusion:Diseases Manifested in the Jaws
There are skeletal disturbances that may present themselves in the mandible and maxillary bone, and therefore may be revealed in radiographs.
Certain characteristics are noted for the particular disturbance. Osteitis fibrosa cystica, also known as Recklinghausen's disease, may result in "a diffuse granular mottling, scattered cystlike radiolucent areas throughout the jaws, and a generalized disappearance of the lamina dura" (Carranza, 574). Paget's disease would cause the trabecular bone pattern to be wool-like in appearance with an absent lamina dura. A patient with fibrous dysplasia would present a trabecular pattern with a ground-glass appearance or simply a small radiolucent area at a root apex. Other disturbances that will be noted during a radiographic interpretation include Langerhans cell histiocytosis, multiple myeloma, oteopetrosis, scleroderma and even a malignancy. Any disturbance affecting the bone will have an impact on the patient's prognosis and treatment, and therefore radiographs must be properly taken and interpreted (TL 8).